MAXILLOFACIAL SURGERY

ALL INDIA INSTITUTE OF MEDICAL SCIENCES, BHUBANESWAR

PRE-OP SURGERY CHECK LIST:

Name of the patient: Proposed date of surgery:
Age: sex: IP no:

1. Diagnosis: Medical conditions:

2. Plan:

3. Pre-op Hb: Blood group: Blood arranged: Y / N, If Yes ____ ʘ

(If blood has to be arranged, blood sample should reach the blood bank at least by 3:00PM, the day before the surgery)

4. Pre-op biopsy: Y / N, if yes – Biopsy date and number / report attached in file:

5. X- Rays present: OPG/ CT / MRI.- Y/N

6. Pre-op Investigations done (CBC, LFT/ RFT, Serology, PT i INR, GRBS & Hba1c (if pt. age
more than 45) ECG, Chest X ray –Y/N Special investigations:

7. Operative implants / Special instruments / implant company……………………………………………

8. Pre Op preparation: Shaving: Y / N

9. Surgery / ICU/ High risk Consent: Y / N PAC done: Y / N

10. Materials required during procedure given to the patient party: Y/N

11. Intubation required: Oral / Nasal / Fiber-optic / Sub-mental / Tracheostomy.

12. Pre-op photos: Y / N ( pre op photos to be uploaded in the group before the Sx date)

13. Post op ICU requirement: Y / N, if yes, informed anesthesia: Y / N.

14. BSKY approval – done / pending Materials --- Y/ N

Check list prepared by and signature of the resident (SR) (with date and time)